'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

The challenges facing general practice are well recognised. For many years general practice has received less attention, less additional funding and lower increases in GP numbers compared with the medical workforce in community or hospital-based care. Practice closures are at their highest for years and GPs are increasingly concerned about financial sustainability. Workforce is also a key aspect on everyone’s minds.

Worryingly, the vast majority of respondents (87%) were either ‘not at all confident’ or had ‘some concern’ about the financial outlook for their practice in two to three years’ time. Fewer than 2% were highly confident. The most significant financial pressures were considered to be inability to meet existing/ growing demand within current core funding (94%), growth in obligatory costs (92%) and capacity required to provide additional activity (90%). This resonates with what workers are feeling on the frontline.

Notwithstanding these views about the financial outlook, just under two thirds of respondents believe that their practice will still exist in five years’ time as an independent organisation or as part of a larger primary care organisation, for example a federation, alliance or expanded partnership. The remainder thought that their services would be provided by either acute or community services.

We can, therefore, expect significant service redevelopment over the next few years as new federations, alliances and partnerships are established. Change at this scale will bring both opportunities and challenges with a range of cultural and practical barriers to be overcome. There is no one size fits all solution, but the research shows that GPs view mergers and federations more likely to support general practice sustainability, rather than integrating with acute or community services.

GPs and practice managers are very clear about the areas where their financial knowledge needs to be improved. Unsurprisingly they are very comfortable with the majority of general practice finance as they know this area well, the only exception being the financial implications of federation or alliance working. Looking across the horizon they were less confident about NHS finance and were particularly keen on developing their understanding of clinical commissioning group (CCG) finance, NHS contracts, NHS England’s Five-year forward view and the national and local financial challenge.

Developing knowledge in these areas will be essential as new working models are developed. Where GPs and practice managers are involved in the development of new pathways and potential innovations, they need the financial skills, finance manager input and robust cost information to complement the clinical appraisal, in reaching decisions.

The HFMA has a range of e-Learning modules that address these areas. They are also working with the National Association of Primary Care to develop training material focusing specifically on general practice finance, which is expected to be available next year.

More training is not the only answer. The research also highlights that is significant room for improvement in the quality of the relationship between general practice and CCGs. GPs would value better quality of contact and communication from CCGs and more support and collaboration than performance management. In the future they may also be forming relationships with sustainability and transformation partnerships.

GPs cannot secure the future of general practice on their own. Part of the solution to improving sustainability should involve reducing the administrative burden, partnership working, and improving trust and relationships. CCGs also have an important role in facilitating the journey for practices as they ally or federate with others over the next few years.

Future surveys could look at this moving landscape and ask the GP community what their real needs are, in order to equip them with practical solutions for even better quality and value service delivery, improved outcomes and better patient and staff experience.

Good primary care is the cornerstone of the NHS. GPs need to consider what their vision is for holistic primary care and work with the finance community to achieve it.

The FFF/ HFMA briefing The financial challenges facing general practice can be found here. More details about the HFMA’s e-Learning material can be found here.